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Diurnal cortisol slopes and mental and physical health outcomes: A systematic review and meta-analysis
Open accessAbstract
Changes in levels of the stress-sensitive hormone cortisol from morning to evening are referred to as diurnal cortisol slopes. Flatter diurnal cortisol slopes have been proposed as a mediator between chronic psychosocial stress and poor mental and physical health outcomes in past theory and research. Surprisingly, neither a systematic nor a meta-analytic review of associations between diurnal cortisol slopes and health has been conducted to date, despite extensive literature on the topic. The current systematic review and meta-analysis examined associations between diurnal cortisol slopes and physical and mental health outcomes. Analyses were based on 179 associations from 80 studies for the time period up to January 31, 2015. Results indicated a significant association between flatter diurnal cortisol slopes and poorer health across all studies (average effect size, r=0.147). Further, flatter diurnal cortisol slopes were associated with poorer health in 10 out of 12 subtypes of emotional and physical health outcomes examined. Among these subtypes, the effect size was largest for immune/inflammation outcomes (r=0.288). Potential moderators of the associations between diurnal cortisol slopes and health outcomes were examined, including type of slope measure and study quality indices. The possible roles of flatter slopes as either a marker or a mechanism for disease etiology are discussed. We argue that flatter diurnal cortisol slopes may both reflect and contribute to stress-related dysregulation of central and peripheral circadian mechanisms, with corresponding downstream effects on multiple aspects of biology, behavior, and health.
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“suggesting cortisol regulation plays a key mediating role in the relationship between stress exposure and later negative health outcomes (Adam et al., 2017; Chrousos and Gold, 1992; O ' Connor et al., 2021).”
From Effectiveness of stress management interventions to change cortisol levels: a systematic review and meta-analysis. (2024) · cites this paper as Adam et al., 2017
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
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“Determining the quality of the cortisol measurements in the included studies was imperative to consider because the methods of cortisol collection are likely to impact study findings of intervention effective ness (Adam et al., 2017).”
From Effectiveness of stress management interventions to change cortisol levels: a systematic review and meta-analysis. (2024) · cites this paper as Adam et al., 2017
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“exposure to chronic stress is a major contributor that leads to slope flattening”
From Strong Enough to Suffer: Emotional Suppression, Stress Exposure, and Physiological Health Among Men Across the Life Course (2026) · cites this paper as Adam et al., 2017
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“In a meta-analysis of diurnal cortisol slope and mental and physical health outcomes in 72 studies, Adam et al. (2017) found that flatter slopes in the morning were predictors of a higher mortality risk, adverse cardiovascular outcomes, and higher levels of mental health symptoms.”
From Strong Enough to Suffer: Emotional Suppression, Stress Exposure, and Physiological Health Among Men Across the Life Course (2026) · cites this paper as Adam et al., 2017
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“Loneliness affects youth’s diurnal cortisol, a key stress hormone [83, 84], potentially causing chronic increases in cortisol in young adulthood, leading to higher risks of depression, anxiety, inflammation, and other adverse health outcomes [85–87].”
From The prospective association of adolescent loneliness and low resilience with anxiety and depression in young adulthood: The HUNT study (2025) · cites this paper as [83]
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Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement
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Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement.
(2009) · PubMed Central · Cited by 44,859
Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement
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Effects of stress throughout the lifespan on the brain, behaviour and cognition
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Research works printed but not linked: 1
- *Gold, 2009, Flatter diurnal cortisol slope is associated with regional hippocampal atrophy and depressive symptoms in multiple sclerosis, Mult. Scler., 15, 1390
Cited by
Sorted by citations
Stress and Health: A Review of Psychobiological Processes
O'Connor, D. B., Thayer, J. F., & Vedhara, K. (2021) · Annual Review of Psychology · doi:10.1146/annurev-psych-062520-122331 · Cited by 948
Diamond, L. M., & Alley, J. (2022) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2022.104720 · Cited by 412
Steptoe, A. (2019) · Annual Review of Public Health · doi:10.1146/annurev-publhealth-040218-044150 · Cited by 474
Students’ mental health problems before, during, and after COVID-19 lockdown in Italy
Meda, N., Pardini, S., Slongo, I., Bodini, L., Zordan, M. A., Rigobello, P., Visioli, F., & Novara, C. (2021) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2020.12.045 · Cited by 398
Heckenberg, R. A., Eddy, P. J., Kent, S., & Wright, B. J. (2018) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2018.09.010 · Cited by 249
Metadata
- Authors
- Adam, E. K., Quinn, M. E., Tavernier, R., McQuillan, M. T., Dahlke, K. A., & Gilbert, K. E.
- Affiliations
- Northwestern University (US)
- Wesleyan University (US)
- American Institutes for Research (US)
- Washington University in St. Louis (US)
- Corresponding author
- Adam, Emma K.
- Venue
- Psychoneuroendocrinology
- Publisher
- Elsevier BV
- Published
- 2017-09
- Volume
- 83
- Pages
- 25-41
- ISSN
- 0306-4530 (ISSN-L)
- PMC
- PMC5568897
- OpenAlex
- W2618888428
- Cited by
- 905
- References
- 161
- Citations by year
- 2026: 113 · 2025: 115 · 2024: 104 · 2023: 100 · 2022: 133 · 2021: 112 · 2020: 128 · 2019: 59 · 2018: 38 · 2017: 2
- FWCI
- 5.47
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Locations
- Psychoneuroendocrinology (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute on Alcohol Abuse and Alcoholism (R21AA021073)
- National Institute of Mental Health (T32MH100019)
- Topics
- Life Sciences › Neuroscience › Behavioral Neuroscience › Stress Responses and Cortisol
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Adrenal Hormones and Disorders
- Life Sciences › Neuroscience › Endocrine and Autonomic Systems › Circadian rhythm and melatonin
- Keywords
- diurnal cortisol slope, cortisol, psychosocial stress, mental health, physical health, immune function, inflammation, circadian rhythm, health outcomes
- MeSH terms
- Circadian Rhythm, Emotions, Female, Humans, Hydrocortisone, Hypothalamo-Hypophyseal System, Male, Mental Health, Pituitary-Adrenal System, Saliva, Stress, Psychological
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